Elder Abuse: General Information
Laurel H. Krouse, MD
Background: Over the past 35 years, tremendous strides have been made in identifying and increasing awareness about patterns of abusive relationships. Child abuse and domestic violence have received significantly more recognition than elder abuse and continue to receive more attention in both public and medical domains, although abuse clearly occurs in persons of all ages. People are living longer with current medical advances and healthier lifestyles. In 1990, it was estimated that older persons comprised just 13% of the US population. By the year 2050, this proportion is projected to increase to 25%; the number of people older than 85 years is expected to double. As a result, the number of elder abuse cases will increase, and the impact of elder abuse as a public health issue will grow. Aging adults involved in abusive relationships often visit the ED for treatment. Emergency physicians are well positioned to help these victims. The terminology used to describe elder abuse is not consistent. Terms vary among researchers, and usage is not consistent in the laws of different states. Even the age at which a person is considered elderly, usually 60 or 65 years, is debated. Seven categories of elder abuse have been described by the National Center on Elder Abuse (NCEA), formerly the National Aging Resource Center on Elder Abuse. Categories include the following: Physical abuse is defined as any act of violence that causes pain, injury, impairment, or disease, including striking, pushing, force-feeding, and improper use of physical restraints or medication. Psychological or emotional abuse is conduct that causes mental anguish. Examples include threats, verbal or nonverbal insults, isolation, and humiliation. Some legal definitions require identification of at least 10 episodes of this type of behavior within a single year to constitute abuse. Financial abuse is misuse of an elderly person's money or assets for personal gain. Acts such as stealing (eg, money, social security checks, possessions) or coercion (eg, changing a will, assuming power of attorney) constitute financial abuse. Neglect is the failure of a caretaker to provide for the patient's basic needs. As in the previous examples of abuse, neglect can be physical, emotional, or financial. Physical neglect is failure to provide eyeglasses or dentures, preventive health care, safety precautions, or hygiene. Emotional neglect includes failure to provide social stimulation (eg, leaving an older person alone for extended periods). Financial neglect involves failure to use the resources available to restore or maintain the well-being of the aging adult. Sexual abuse is defined as nonconsensual intimate contact or exposure or any similar activity when the patient is incapable of giving consent. Family members, friends, institutional employees, and fellow patients can commit sexual abuse. Self-neglect is behavior in which seniors compromise their own health and safety, as when an aging adult refuses needed help with various daily activities. When the patient is deemed competent, many ethical questions arise regarding the patient's right of autonomy and the physician's oath of beneficence. The miscellaneous category includes all other types of abuse, including violation of personal rights (eg, failing to respect the aging person's dignity and autonomy), medical abuse, and abandonment. Frequency: In the US: Due to the inconsistencies in definitions of elder abuse, obtaining accurate information on elder abuse incidence is difficult. A 1991 report from the House Select Committee on Aging suggests that 1-2 million adults older than 60 years are abused each year. Other studies suggest that 3-10% of elders are abused or neglected. Many factors (eg, fear, shame, guilt, ignorance) play a role in the likely underestimation of the number of abused elders. In addition, many studies routinely exclude certain populations (eg, persons possibly unable to respond to a survey, speakers of languages other than English, persons with mental illness), further complicating accurate tallies of the number of older persons who are abused. Race: Elder abuse occurs among members of all racial, socioeconomic, and religious backgrounds. The NCEA found the following racial and ethnic distribution among older persons who had been abused: White, non-Hispanic – 66.4% Black – 18.7% Hispanic – 10% Other – 4.9% Sex: Women are believed to be the most common victims of abuse, perhaps because they report abuse at higher rates or because the severity of injury in women typically is greater than in men. Numerous studies, however, have found no differences based on sex. Age: By definition, elder abuse occurs in the elderly, although there is no universally accepted definition of when old age begins. Typically, 60 or 65 years is considered the threshold of old age. History: The American Medical Association recommends that doctors routinely ask geriatric patients about abuse, even if signs are absent. Keeping questions direct and simple and asking in a nonjudgmental or nonthreatening manner increases the likelihood that patients will respond candidly. The patient and the caregiver should be interviewed together and separately to detect disparities offering clues to the diagnosis of abuse. Accurate, objective documentation of the interview is essential. The following questions can be used to elicit information about elder abuse. Physical abuse Are you afraid of anyone at home? Have you been struck, slapped, or kicked? Have you been tied down or locked in a room? Have you been force-fed? Psychological abuse Do you ever feel alone? Have you been threatened with punishment, deprivation, or institutionalization? Have you received "the silent treatment"? Do you receive routine news or information? What happens when you and your caregiver disagree? Sexual abuse: Has anyone touched you in a sexual way without permission? Neglect Do you lack items such as eyeglasses, hearing aids, or false teeth? Have you been left alone for long periods? Is your home safe? Has anyone failed to help you care for yourself when you needed assistance? Financial abuse Is money being stolen from you or used inappropriately? Have you been forced to sign a power of attorney, will, or another document against your wishes? Have you been forced to make purchases against your wishes? Does your caregiver depend on you for financial support? Follow-up questions (if abuse is identified) How long has the abuse been occurring? Is it an isolated incident? Why do you think this happens? When do you think the next episode will occur? Is the abuser present in the ED? Is it safe for you to return home? What would you like to see happen? Have you ever received help for this problem before? Physical: As with other abusive relationships, elder abuse rarely resolves itself and probably will escalate over time. Signs of abuse may be blatant or subtle. A study by Lachs et al failed to show a specific injury type or pattern common to elderly persons who had been abused; therefore, consider abuse in the differential diagnosis of every elderly person entering the ED. A number of clinical findings and observations make elder abuse a strong possibility, including the following: Several injuries in various stages of evolution Unexplained injuries Delay in seeking treatment Injuries inconsistent with history Contradictory explanations given by the patient and caregiver Laboratory findings indicating underdosage or overdosage of medications Bruises, welts, lacerations, rope marks, burns Venereal disease or genital infections Dehydration, malnutrition, decubitus ulcers, poor hygiene Signs of withdrawal, depression, agitation, or infantile behavior Causes: Many theories have been developed to explain abusive behavior toward elderly people. Clearly, no single answer exists to explain behavior in an abusive relationship. A number of psychosocial and cultural factors are involved. Theories of the origin of mistreatment of elders have been divided into 4 major categories, as follows: physical and mental impairment of the patient, caregiver stress, transgenerational violence, and psychopathology in the abuser. Physical and mental impairment of the patient Recent studies have failed to show direct correlation between patient frailty and abuse, even though it had been assumed that frailty itself was a risk factor for abuse. Physical and mental impairment nevertheless appear to play an indirect role in elder abuse, decreasing seniors' ability to defend themselves or to escape, thus increasing vulnerability. Caregiver stress This theory suggests that elder abuse is caused by the stress associated with caring for an elderly patient, compounded by stresses from the outside world. The effect of stress factors (eg, alcohol or drug abuse, potential for injury from falls, incontinence, elderly persons' violent verbal behavior, employment problems, low income on the part of the abuser) may all culminate in caregivers' expressions of anger or antagonism toward the elderly person, resulting in violence. This theory, however, does not explain how individuals in identically stressful situations manage without abusing seniors in their care. Stress should be seen more as a trigger for abuse than as a cause. Transgenerational violence: This theory asserts that family violence is a learned behavior that is passed down from generation to generation. Thus, the child who was once abused by the parent continues the cycle of violence when both are older. Psychopathology in the abuser: This theory focuses on a psychological deficiency in the development of the abuser. Drug and alcohol addiction, personality disorders, mental retardation, dementia, and other conditions can increase the likelihood of elder abuse. In fact, family members with such conditions are most likely to be primary caretakers for elderly relatives because they are the individuals typically at home due to lack of employment. Other risk factors in abuse are (1) shared living arrangements between the elder person and the abuser, (2) dependence of the abuser on the victim, and (3) social isolation of the elder person.
Sources:
Elder Abuse Articles
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